| NPI | 1205523164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 61626132) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2023-04-20 |
| Last Update Date | 2024-12-12 |